Clinicians Reduce Antibiotic Overuse Using Simulation Tool

A virtual simulation allows clinicians to role play to improve clinician-patient communication.
A virtual simulation allows clinicians to role play to improve clinician-patient communication.

The rapid emergence of antibiotic-resistant bacteria is a dangerous worldwide phenomenon primarily driven by overuse and misuse of these medications.1 Antibiotic-resistant infections account for an estimated 2 million illnesses and 23,000 deaths in the United States annually.2 In 2011, US clinicians prescribed 262.5 million outpatient courses of antibiotics, one-fourth of which were prescribed by family physicians.3

Many clinicians attribute inappropriate antibiotic prescriptions to patient pressure and the desire for customer satisfaction.4 But numerous studies have shown that even patients who expect antibiotics are willing to forego them if clinicians explain why antibiotics are not needed, provide positive treatment recommendations, suggest contingency plans, and engage in shared decision-making.5-7 Educating clinicians in the art of communication is essential for conducting effective conversations with patients. In fact, improving patient/clinician communication has been shown to reduce antibiotic prescriptions.8-10

To meet this educational need, Conversations for Health, an innovative simulation created by Kognito and funded by the Robert Wood Johnson Foundation, offers clinicians the ability to engage in role-play conversations about antibiotics with virtual patients as a way to build competency to effectively lead them in real-life.

MPR interviewed Ron Goldman, Co-Founder and CEO of Kognito to understand more about this innovative educational tool.

MPR: What is Conversations for Health?

Ron Goldman: Conversations for Health is a series of interactive simulations designed to help improve clinician–patient communication. Kognito works in the field of interactive online simulations, with a goal of preparing individuals to lead conversations in real life that can improve emotional, social, and physical health. Our goal is to improve health-related conversations between healthcare professionals, patients, teachers, students, parents, and caregivers. We know that these conversations, when managed well, have tremendous ability and power to improve health outcomes by improving patient engagement, improving patients' comfort in sharing their concerns, improving the patient's understanding, and improving adherence to the recommended treatment plan. Our philosophy is that no one learns to ride a bike by watching someone else ride a bike. You need to personally learn what works and what does not work. This is what we do in our simulations. We allow the clinician to have a conversation with a virtual human being, and see what is and is not effective. 

How did you get involved with Conversations for Health?

My background involves expertise in game technology and entrepreneurship. I partnered with Glenn Albright, PhD, Co-Founder and Director of Research at Kognito, who is a clinical psychologist with specialty in learning design and social cognition. We combined these 2 disciplines to create experiences and simulations that could improve people's ability to lead health conversations.

How does Conversations for Health deliver education regarding communicating with patients about antibiotics?

We offer 2 simulations, one for patients and one for clinicians. The simulation allows the participant to engage in practice conversations about the overuse of antibiotics by playing the role of a clinician conducting an office visit with “Laura,” a patient who has been coughing for a week and believes that antibiotics can help her get better quickly. The clinician's task is to engage Laura in a conversation about her condition and health goals and then collaborate with her on a treatment plan that she understands and is motivated to follow. The participant chooses from a menu of options of what the clinician can say to Laura that will provide empathy and explanation, and arrive at a shared treatment plan. At various junctures, Martin Blaser, MD, Director of the NYU Human Microbiome Program and Chair, Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria, offers commentary and feedback on the physician's choices of response. A similar simulation is offered for patients.

Have any studies investigated the effectiveness of the Conversations for Health simulation in reducing antibiotic overprescribing?

A pilot study, conducted by Antoinette Schoenthaler, EdD, at the NYU School of Medicine's Center for Healthful Behavior Change, examined the potential utility of 2 simulations designed to promote effective communication regarding antibiotic prescription and collaborative decision-making between healthcare clinicians and patients. In the study, primary care clinicians (n=34) and patients (n=33) completed a pre-survey and then experienced a 7- to 12-minute conversation simulation, followed by a post-survey, and a 1-month follow-up survey.

Clinicians reported that the simulation was a much better learning tool than standardized teaching models, as they felt more comfortable making decisions within the virtual space. At 1-month follow-up, 77% reported that the simulation had a positive impact on the way they communicate with patients; 65% indicated that it helped them have a conversation with patients about antibiotics, 94% said they intended to further invite patients to ask questions and participate in decision-making, 89% said they would recommend the simulation to other professionals, and 100% said they would recommend it to medical students and residents.

Almost all patients (97%) rated it as a very useful tool, saying that it would help them to be better prepared for a medical appointment, increase assertiveness when communicating with their clinician, create a treatment plan, and learn specific content about antibiotics. At 1-month follow-up, 79% of patients who saw their clinician after completing the simulation reported that it helped them talk with their clinician; 87% said they would recommend it to friends and family.

Have any medical societies recommended education about antibiotic prescriptions through Conversations for Health?

The Choosing Wisely Campaign, which is an initiative of the American Board of Internal Medicine (ABIM) Foundation, included Conversations for Health as a resource to “help clinicians and patients engage in informed conversations about when antibiotics may not be needed.”11 And the CDC, which initiated the “Get Smart About Antibiotics Week” (November 14 to 20, 2016), also posted it on the resource page for clinicians and consumers.12

Do you offer education about other topics?

Over the past 6 years, we developed many simulations for health professionals, parents, patients, caregivers, educators, and youth on a variety of emotional, social, and physical health topics. For example, we offer a simulation in which the participant plays the role of a family support clinician who is coaching a single parent how to read with her son. In another simulation, the participant plays the role of a parent who must manage the behavior of a young child during common stressful situations. We also worked with the American Academy of Pediatrics, Institute for Healthy Childhood Weight to develop Change Talk, “a web and mobile app to help health professionals utilize motivational interviewing to navigate challenging family and patient conversations regarding childhood obesity.”13 This intervention was studied14 and found to be effective. Other simulations we created deal with helping at-risk college students, at-risk high school students, and veterans experiencing post-deployment stress. These simulation are listed in SAMHSA's National Registry of Evidence-Based Programs and Practices (NREPP).15 We are developing other simulations on topics such as opioids, substance use, end-of-life conversations, and general patient-physician communication. 

References

  1. Ventola CL. The antibiotic resistance crisis: Part 1: causes and threats. PT. 2015;40(4):277-283.
  2. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed: December 6, 2016.
  3. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308–1316.
  4. Fleming-Dutra KE, Mangione-Smith R, Hicks LA. How to prescribe fewer unnecessary antibiotics: talking points that work with patients and their families. Am Fam Physician. 2016 Aug 1;94(3):200-2.
  5. Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800–806.
  6. Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med. 2015;13(3):221–227.
  7. Coxeter P, Del Mar CB, McGregor L, et al. Cochrane Database Syst Rev. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. 2015 Nov 12;(11):CD010907.
  8. Cals JW, de Bock L, Beckers PJ, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med. 2013;11(2):157–164.
  9. Cals JW, Scheppers NA, Hopstaken RM, et al. Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice. Patient Educ Couns. 2007;68(3):270–278.
  10. Altiner A, Brockmann S, Sielk M, et al. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother. 2007 Sep;60(3):638-44.
  11. Choosing Wisely. To-Do Next Week: Get Smart About Antibiotics. Available at: http://www.choosingwisely.org/resources/updates-from-the-field/to-do-next-week-get-smart-about-antibiotics/. Accessed: December 7, 2016.
  12. Centers for Disease Control and Prevention (CDC). Get Smart: Know When Antibiotics Work. Continuing Education and Curriculum Opportunities. Available at: http://www.cdc.gov/getsmart/community/for-hcp/continuing-education.html. Accessed: December 8, 2016.
  13. Radecki L, Goldman R, Baker A, et al. Are pediatricians “game”? Reducing childhood obesity by training clinicians to use motivational interviewing through role-play simulations with avatars. Games for Health Journal. 2013;2(3):174-178.
  14. Available at: https://ihcw.aap.org/Documents/ChangeTalkCaseStudy.pdf. Accessed: December 8, 2016.
  15. Substance Abuse and Mental Health Services Administration (SAMHSA). National Registry of Evidence-Based Services and Practices (NREPP). Learning Center. Available at: http://nrepp.samhsa.gov/05_learning.aspx. Accessed: December 7, 2016.
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